The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?

Choice A reason:

Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.

Choice B reason:

Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.

Choice C reason:

Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.

The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.

Choice D reason:

Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.

The correct answer is: c. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Choice A reason:

If this baby was born vaginally, it could indicate a pneumothorax.

A pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This condition can happen in newborns, especially those with underlying lung issues or those who have undergone mechanical ventilation However, moist lung sounds in a newborn are not typically indicative of a pneumothorax. Pneumothorax is more likely to present with symptoms such as rapid breathing, grunting, and cyanosis.

Choice B reason:

The neonate must have aspirated surfactant.

Surfactant aspiration is not a common cause of moist lung sounds. Surfactant is a substance that helps keep the lungs’ air sacs open and is crucial for proper lung function. Aspiration of surfactant is not a typical diagnosis and would not usually result in moist lung sounds. Instead, surfactant deficiency or dysfunction can lead to respiratory distress syndrome, which presents differently.

Choice C reason:

The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Babies born via cesarean section often have moist lung sounds because they do not experience the compression of the chest that occurs during vaginal delivery, which helps expel fluid from the lungs. This retained fluid can cause moist lung sounds, which typically resolve within the first 24 hours after birth. This is a normal finding and does not usually indicate a serious problem.

Choice D reason:

The nurse should notify the pediatrician stat for this emergency situation.

While it is always important to monitor newborns closely, moist lung sounds alone in a baby born via cesarean section are not typically an emergency. This finding is usually due to retained fluid in the lungs, which is expected to clear within the first day of life. Immediate notification of the pediatrician is not necessary unless the baby shows other signs of respiratory distress or other concerning symptoms.